The current use of e-health tools and services within the health care industry – including the adoption of electronic health records (EHRs) by physician and hospitals, the development of electronic health information exchange (HIE) networks, and the maturation of the telemedicine market – clearly contributed positively to the quality of, and access to health care services for individuals affected by Hurricane Harvey. While the adoption of some of these tools and services is being driven by a combination of strong market forces and public policy, electronic HIE networks have not consistently identified sustainable business models despite their benefits. Electronic HIE networks should be considered a critical part of a state’s and region’s emergency preparedness and response infrastructure, and should receive corresponding public financial support.
Hurricane Harvey made landfall on August 25, 2017 around midnight on the Texas coast near Port Aransas as a category four hurricane. Over the next week, it would move east and linger over Houston, the fourth-largest city in the U.S. with a metropolitan population of over six million, dropping over 50 inches of rain in some places and causing massive flooding. Although officials did not call for a mandatory evacuation of Houston, many individuals left ahead of the storm and many more were subsequently displaced due to dangerous conditions and storm-damaged homes.
In an evacuation scenario, after the immediate needs of safety, shelter, food, and water are addressed, access to health care services becomes very important, particularly for those with chronic conditions. One of the lasting impressions from Hurricane Katrina, just over 16 years earlier, was the challenge of providing health care to a large and displaced population without access to past medical records. At the state level, the Medicaid program negotiated an emergency waiver with the Centers for Medicare and Medicaid Services (CMS) over the course of 2 weeks. (Helping to coordinate the Texas Medicaid response to Hurricane Katrina remains one of the most formative experiences of my professional life.) With the emergency Medicaid waiver in place, there would be a way for providers to get paid for providing services, but issues with discontinuity of care and an inadequate supply of health care professionals still needed to be addressed.
Physicians providing care at emergency shelters told stories about elderly patients trying to describe their medications by color and shape, or arriving with plastic bags full of mostly-dissolved, multi-colored, medicinal slurry. The separation of these evacuees from their usual points of care also created issues of access because there were not enough providers to provide care to so many new arrivals. In addition to contributing to the disruption of patient continuity of care, the reliance by the physicians and hospitals of New Orleans on paper medical records, many of which were destroyed in the storm, made it harder for providers to get back into business.
Fast-forward to today. Almost all hospitals are now using electronic health records (EHRs), electronic health information exchange (HIE) networks are in place in many areas, and telemedicine is a common and growing medical service modality. The journey for e-health from Katrina to Harvey has been driven by a mix of public policy and market forces, and is far from complete, but the e-health success stories out of Houston over the past month, contrasted with the challenges faced during Katrina due to a lack of e-health, show just how far we have come.
In 2005, most doctors and hospitals did not use EHRs, and electronic HIE networks were few and far between, making it very unlikely for patient data to be available to providers outside of the office or facility where care was initially delivered. Nonetheless, as it became clear during the response to Hurricane Katrina that access to past medical information would be helpful, several industry players quickly developed a stopgap solution in the form of a website called KatrinaHealth.org. With medication data from two large pharmacy networks and access facilitated by the American Medical Association, KatrinaHealth.org was deployed to the main shelters housing evacuees and provided electronic medication history to support the delivery of care. KatrinaHealth was also utilized during the evacuation of Houston before Hurricane Rita struck just 25 days later and was later re-branded to ICERx (In Case of Emergency Rx), which has since been decommissioned.
Soon after Hurricanes Katrina and Rita, David Brailer, the first National Health Information Technology (IT) Coordinator established the Gulf Cost Health IT Task Force and charged it with identifying opportunities for leveraging health IT to support the health care response to hurricanes along the Gulf Coast. (I was fortunate enough to participate on the Task Force as one of Governor Rick Perry’s appointees to the Texas delegation.) The recommendations that emerged from the work of the Gulf Coast Health IT Task Force largely focused on increasing the adoption and use of EHRs and the establishment of mechanisms for sharing health information electronically. (A more recent federal report, to which I contributed, elaborated on the role of HIE in emergency preparedness and response.) While those goals were developed in the context of hurricane preparedness and response, they have the benefit of being much more widely applicable as well.
During and after Hurricane Harvey, the e-health situation has been very different. Since 2005, several major public programs have been established to encourage the adoption and use of EHRs and the development of electronic HIE networks. Today, almost all hospitals and a significant majority of physicians are using EHRs, many of which are natively compatible with HIE networks. There are also regional electronic HIE networks in many areas, and an increasingly robust and interoperable set of national HIE networks. In addition, telemedicine vendors have matured and state regulations governing the practice of medicine have been modernized to more appropriately accommodate technological opportunities like telemedicine.
There have been numerous specific e-health success stories coming out of the post-Harvey world. In a move similar to KatrinaHealth and ICERx, a major pharmacy network and an EHR company have partnered to give pharmacists access to electronic medication history. (These days, physicians and hospitals generally already have such access through their electronic prescribing or medication reconciliation services.) By numerous accounts, provider EHRs continued to function and proved invaluable in supporting medical services before, during, and after the storm. Electronic HIE networks serving several of the state’s major urban areas enabled clinical data to be accessible across providers and between cities, and worked with health care providers in emergency shelters to ensure that they knew how to use the services and access the data. Several of the most prominent telemedicine companies offered free telemedicine visits to victims of Harvey, which probably would not have been possible even a year ago due to the antiquated public policy framework for telemedicine in Texas that was only modernized earlier this year.
Clearly, the health care industry has come a long way in the last 16 years in its adoption of e-health tools and services, and the e-health industry has grown significantly as well during that time. While EHRs have come into widespread adoption, and the telemedicine market appears to have significant momentum, electronic HIE networks have struggled with financial sustainability. Given their significant role in supporting the delivery of health care during and after disasters, state and local policy makers and budget writers should consider including public funding for HIE as part of their preparedness and response plans.